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Are Any of the Paraphilias in DSM Mental Disorders? }

Charles Moser, Ph.D., M.D., 
Institute for Advanced Study of Human Sexuality, 
45 Castro St., No. 125, San Francisco, California 94114 
(e-mail: docx2@ix.netcom.com


I would like to thank Peggy J. Kleinplatz for her comments and editorial assistance.

Three decades ago, Green (1972) argued that homosexuality did not meet the definition of a mental disorder and, by implication, should not be listed in the DSM. Now, he continues this line of reasoning by suggesting that pedophilia also does not meet the criteria for a mental disorder. My comments are meant to expand upon his point.

The assumption that certain strong, sexual interests are mental disorders has pervaded the DSM since its inception and has been promulgated from edition to edition without serious review. 

I ask the obvious questions: 

Are any of the paraphilias mental disorders? 
Do the paraphilias meet the DSM definition of a mental disorder? 
Are there data to support the inclusion of any paraphilia diagnosis in the DSM? 
Do we need to argue separately about the removal of each paraphilia from the DSM? 

I believe the answers to all these questions is "No!"

The DSM-IV-TR (American Psychiatric Association, 2000) purports to be both culturally sensitive and supported by an extensive empirical foundation. However, in the case of the paraphilias, both of these are in doubt. The assumption that the paraphilias constitute psychopathology is erroneous and is not supported by objective research. 

On the contrary, any sexual interest can be healthy and life-enhancing. Historically and cross-culturally, there are numerous examples of sexual interests that were proscribed and are now accepted and interests that were accepted and are now proscribed. This supports the view that sexual interests occur in cultural context and are judged relative to the prevailing social norms. We could view the individual who cannot accept the nontraditional lifestyle choices of others as having a mental disorder, rather than


blaming the "cause" of their discomfort. The socio-political context in which the diagnostic process occurs should not be ignored, nor its consequences.

Any sexual interest, even a "normophilic" interest (i.e., the supposedly healthy ideal), can be an appropriate focus for a mental health intervention. The clinician should first assess whether there is a problem. If so, is the sexual interest actually the cause of the problem? The "paraphilia" could be unrelated to the problem or it may be the reaction of others that is problematic. A diagnostic paradigm that classifies specific, sexual interests as pathological implies the interests per se are the cause of problems and that eliminating these interests will resolve the problems. Such a paradigm equates the sexual interest with the disorder, even when the sexuality is experienced as life-enhancing and does not cause distress or disability.

The presence of paraphilias as a category of mental disorders in the DSM has unintended political and social implications. Individuals lose jobs, security clearances, child custody, and other rights on the basis of being branded with a psychiatric diagnosis. One's career, self-esteem, and relationships can be affected negatively by a stigmatizing diagnosis. Trying to live a "normophilic" lifestyle is difficult and problematic for both those with unusual sexual interests and their partners. Attempts at transforming their unusual sexual interests to conventional ones are hindered by a dearth of effective treatments. 

Despite the beliefs of some therapists, there is a paucity of data to suggest that psychotherapy or just plain will power can alter the character of any sexual interest. Medical interventions (e.g., SSRI's and anti-androgens) can decrease unusual sexual desires, but often result in hypoactive sexual desire or sexual arousal disorders. To paraphrase from Schmidt's article, those who have unusual sexual interests and must deny themselves the experience of love and sexuality deserve our respect, rather than our contempt.

Even when distress or disability is related to the interest itself, eradicating the interest may not be the appropriate therapeutic goal. The death of a parent may trigger an episode of clinical depression, but not everyone who loses a parent will become clinically depressed. Although some depressive symptoms may be common, they are not present in all individuals who lose a parent. 

In short, depression is the diagnosis, rather than the loss of the parent. Treatment may focus on the loss of the parent, but will necessarily target other issues. The intended outcome will be an individual without depression who has suffered a parent's death. Trying to eradicate the patient's feelings for the deceased parent is obviously inappropriate. The intended treatment outcome with a "paraphilic" patient will be an individual with an atypical sexual interest, who is no longer distressed or dysfunctional.

Therapists and physicians commonly attempt to help normophilic individuals enrich their sexual lives. Medical, surgical, and psychotherapeutic treatments of sexual dysfunctions are common, targeting the distress and difficulties these individuals experience. 

The same consideration should be given to unusual sexual interests; their repression also can affect one's quality of life adversely. I am not advocating the change of any law or acceptance of inappropriate sexual behavior; society clearly has the right and obligation to protect its citizens from unwanted or predatory sexual advances. People who break laws are criminals, not necessarily mentally disordered.

Sexuality can be a source of tremendous satisfaction in our lives. We should help our patients reach their sexual potential, not limit it by pathologizing individuals a priori, based only on the nature of their desires. A rational and compassionate approach requires that we stop viewing unconventional sexual expression as pathological. The paraphilia section of the DSM should be removed and replaced with a generic diagnosis that does not identify the specific behavior (for one such proposal, see Moser, 2001).

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